Supportive survival

The crucial ingredient to Bill and Sue Brannon’s 50 years of marriage, they say, is the fact that they bear through every trial with a cheerful attitude.

Bill and Sue Brannon have been married 50 years. Both have Type 2 diabetes. Bill’s left leg was amputated below the knee as a result, and Sue has retinopathy, progressive damage to the eye’s retina caused by long-term diabetes, which impairs her vision to the degree that she can’t drive. (Photo courtesy of Bill and Sue Brannon)

“I think both of us have been blessed with good humor,” Sue said, winking at her husband behind her goggle-thick glasses in their St. Charles home.

But the reason they’ve lasted all these years, she added, is that they listened to their doctors.

Even after raising four children, neither were prepared for the surprise awaiting them eight years ago when Bill noticed black splotches growing around a blister on his left foot.

At the hospital emergency room, physicians immediately diagnosed Bill with Type 2 diabetes. On top of that, gangrene had spread from his foot up through the leg.

Two days later, they amputated, leaving Bill with nothing below his left knee.

Reclining on a beige couch in the couple’s spotless living room, Bill sighed and said he remembered the terror of lying in the hospital bed, not knowing what he would be capable of anymore.

“Two days after the amputation, my youngest son called and he just said, ‘Dad, you’re now in the business of overcoming limitation, and that’s what you’ve got to do. You have to decide to do the best you can with what you’ve got left,’” Bill said.

It wasn’t just the cotton fiber prosthetic below his knee that made him strong enough to return to work and even continue playing golf as a member of the Amputee Golf Association.

The real support, he said, came from Sue.

In the six weeks Bill lay bedridden recuperating after the amputation, she scurried back and forth to his room at the top of the three-story home they shared at the time. She fixed him breakfast, lunch and snacks before leaving for work, and later did the laundry and kept Bill company before she started dinner. She called the fire department to carry him downstairs in a wheelchair for doctor appointments.

“It was extremely taxing on her physically, and I’m sure mentally, too,” he said.

Complications

Some diabetic complications, such as clogged arteries, call for more dire measures. But the last resort in treating arterial plaque build-up is also the most visible: amputation. Cutting off diabetics’ toes and legs occurs four or five times a year at St. Mary’s Health Center in Jefferson City.

Severe arterial plaque build-up affects one in three diabetics and is most likely to occur among the obese and sedentary. High blood pressure and sugar levels damage the inner lining of arteries, allowing cholesterol to seep in, build up and inflame, becoming cholesterol plaque. Unhealthy diet and inactivity increase the build-up, causing artery walls to harden and tighten, clogging blood vessels so they can’t supply oxygen to muscles. Smoking further hardens the arteries, and diabetics who smoke are three times as likely to develop plaque build-up.

For reasons physicians can’t explain, diabetics develop the worst clogging in arteries outside the heart and brain, usually in the legs, a condition called peripheral artery disease.

The arteries in the legs are the most difficult for surgeons to reach via incisions through the skin. Thus, it is often impossible to attempt bypass surgery, in which a vascular surgeon cuts through the limb and connects a synthetic tube above and below where plaque clogs an artery, creating a new pathway for blood flow.

Usually when plaque congests an artery, just enough blood oozes through that diabetics don’t experience warning symptoms, leaving people unaware of their condition until the blood vessel ruptures, causing a blood clot and cutting off circulation altogether. At that point, people may feel pain or cramping in their legs.

When bypass surgery fails or simply can’t be done, the last resort to treating the pain is amputation.

Or so it was until three years ago, when a handful of doctors across the country — and in Missouri — experimented with a new procedure that can now save some limbs with little pain.

When Victor Phillips, a board certified vascular surgeon, began his practice with Jefferson City Medical Group two years ago, the majority of his referrals called for amputations.

“I’ve gotten patients from doctors who’ve seen them and said, ‘There are no options, there’s nothing we can do,’” he said. “Then they come to me, and we fix ’em.”

The alternative to bypass surgery and amputation, called plaque excision, returns to the old fashioned method of endovascular surgery relying on wires and curettes, which few vascular surgeons have the training to perform with the necessary dexterity.

The procedure takes from one to four hours, Phillips said. He begins by puncturing a tiny opening in the groin. Then he slides a wire through the opening, manipulating it with a handle about as thick as a bicycle brake. Feeding the wire down the artery to the site of the blockage is the most difficult aspect of the procedure, he said, but after performing more than 200 plaque excision in the past few years, he quickly responds to the tugs and jerks of the wire like a fisherman responds to a caught line.

When the wire reaches the plaque, a tiny rotating blade ejects from the end and scrapes along the wall of the artery like a toothbrush tickling plaque off of gums. The device sucks up the plaque shavings and stores them in a canister in the handle.

After the wire slides out, the patient stays overnight in the hospital and goes home the next day.

Changes in blood flow are instant. In X-rays from before one procedure, straw-sized arteries bulge with clogged blood, a tangled net of collusion blood vessels growing like tiny roots to compensate for the lack of blood. X-rays taken after the procedure show blood flowing smoothly through the clean artery, the collateral vessels entirely gone.

Phillips said he finds the excision far less risky than cutting incisions for bypass surgery. He can also easily repeat the plaque excision if the arteries clog again, which only occurs among 5 percent of his patients.

“A few years ago, I was treating 80 percent of these patients with bypass surgery and only about 20 percent this way,” Phillips said. “Now I probably treat more than 90 percent this way and 10 percent with bypass.”

Half of his patients are diabetic, he said.

Of course, while plaque excision salvages a limb for the time being, doctors can’t chisel away risk factors like high cholesterol and blood pressure quite as easily. If patients don’t control their diabetes by quitting smoking and lowering blood pressure and LDL cholesterol, vascular disease will continue to plague their bodies and could eventually lead to amputation.

Alan Rauba, an endocrinologist who specializes in diabetic treatment at Jefferson City Medical Group, said he sees this often, and he doesn’t sugarcoat what it means.

“It’s a death sentence,” he said.

The majority of amputees die within two years of their amputation, he said, regardless of which limb has to go.

“When a body is so riddled with vascular disease, it’s going to have a heart attack, a stroke immediately following that, or enter the end stages of kidney failure,” he said.

Typically, five or six of his patients undergo an amputation each year, and he loses the same number. This year, he said, only three patients underwent amputations. More patients simply died.

Mutual support

Eight years later, Sue frowned when Bill prepared to shove off the couch, quickly pushing on his prosthetic leg to confirm that it was firmly attached. As he rose, she straightened in her chair, ready to help whether he asked her to or not.

Sue said they watch out for each other, because they share a common burden. Her optometrist had diagnosed her with Type 2 diabetes only a year before Bill’s diabetes diagnosis. She also was diagnosed with retinopathy, progressive damage to the eye’s retina caused by long-term diabetes. Soon after, she also developed cataracts, which are 60 percent more likely to develop among diabetics. When Sue “falls off the wagon” and eats too much sugar, she said, her eyes blur and blind her for weeks at a time, leaving her equally dependent on Bill.

“I usually say that we’re both walking on Bill’s leg, because he has to do the driving,” she said with a laugh.

Neither gave excuses about how they developed diabetes.

“We grew up in an age where you never thought about your food style, you never thought about your sauces or the butter you used,” Bill said.

Sue used to cook like the chefs on the Food Channel, he said, lathering real butter and mayonnaise on entrees with reckless abandon. “People didn’t have treadmills or things like that, you never thought of it,” he said.

After her eye problems developed and Bill lost his leg, Sue changed her recipes, thanks to diabetic-friendly ingredients that weren’t available during her grandfather’s youth, when he crumbled saccharine tablets into his tea to accommodate his diabetes. She subscribed to a diabetic cooking magazine and searched for low-fat and cholesterol-free labels in the supermarket. After enough practice, Sue boasted, she and Bill ate more delicious meals than most people without diabetes.

Bill said he learned from his mistakes, too. He scours his remaining leg every morning for any infections or wounds and visits his podiatrist every six weeks to double-check the limb and test his circulation. The few times infections developed on his good leg, the doctor caught them in time to heal them with antibiotics.

It’s easy to care for himself when there’s someone beside him trying to do the same, he said.

“I can see where it’s hard for one person to adjust to diabetes,” he said. “But from our standpoint, when we go anywhere, we’re both looking at the same thing, we’re inspired just by helping each other.”

When they eat out, they prod each other to order nutritious dishes, he said, and often share an entree to keep from overeating.

The degree of success in overcoming any challenge, from losing a limb to taking insulin shots, Bill said, is finding a reason to go on living no matter what.

“The greatest thing you can have is a supportive, loving family who takes you as you are,” he said, half smiling at his wife. “That will give you the strength to do better and try to do everything you can.”